Coroner hits out at series of failures following death of elderly man by aneurysm
A CORONER has hit out at a series of failures at Galway University Hospital after an elderly man died from a large aneurysm which was never acted on for over two years after it was detected.
John Joseph Ryder (71) from Aughlora, Tuam, Co Galway died from an abdominal aneurysm which was first detected at University Hospital Galway in May 2009 but was not made known to the patient or his GP and never followed up on.
Mr Ryder has several cardiology reviews in the years following his discharge and attended the hospital up to six times but the aneurysm was never referenced or treated.
He died two years later on November 25, 2011 as a result of the aneurysm.
Recording a verdict of medical misadventure, Galway West Coroner Dr Ciaran MacLoughlin criticised the "failure in communication practices and also a failure in letter writing to the GP".
The inquest heard that by the time of his death, the aneurysm had increased in size from 6cm to 8cm and could rupture at any stage.
The failure to properly record the condition in Mr Ryder's notes or subsequently act on the potentially life threatening condition was described as a "systems failure" by Galway West coroner Dr Ciaran MacLoughlin. Dr MacLoughlin said there was an omission in Mr Ryder's care.
"Had it been acted upon he may very well not have died from a ruptured abdominal aneurysm," he said.
The coroner said there had been a "failure to communicate during ward rounds" and questioned why doctors were not given the full medical history by junior staff during these rounds.
"In this case the very simple system which has worked for generations of doctors did not occur," he said.
He also raised concern about the filling out of discharge letters from the hospital to the GP.
He added that the most important person who should have been told of the condition was Mr Ryder's GP.
"Nobody was aware until the fatal rupture of the aneurysm.
Earlier, a consultant cardiologist apologised to the Ryder family. Cardiologist Dr Jim Crowley, who was first detected the aneurysm in May 5, 2009 today apologised for failing to put in place a follow up plan for Mr Ryder.
On Mr Ryder's admission to hospital 2009 he was critically ill from encephalitis, an extremely rare disorder which causes an inflammation of the brain. An ultrasound discovered the presence of the aneurysm, however, Dr Crowley told the inquest this was not a risk to him at that time which was an "incidental finding" and Mr Ryder would not have been well enough for treatment at the time.
However, he added that it was a potential risk in the future.
"I would like to apologise for not acting upon it subsequently," he added.
It also emerged that Mr Ryder's GP was never notified of the aneurysm with the exception of one notation in a lengthy discharge summary from the hospital, which Dr Crowley accepted could easily have been missed.
He said the condition should have been highlighted and the GP notified and it was incumbent on the hospital to do so.
The consultant added that what should have occurred in this case was surveillance be put in place and six months later when his condition improved, Mr Ryder should have been assessed for possible surgery.
Dr Crowley said the operation was "high risk" and it was not a given that it would have been suggested for Mr Ryder, however, he accepted that the patient should have been made aware of the matter and allowed to consult with his family and doctor on whether to have surgery.
The cardiologist added that had Mr Ryder been referred for treatment in the context of an aneurysm a year later; "I think it would be completely dfferent".
Mr Ryder's daughter Caroline Gordon told the inquest that the family had never been told of their father's aneurysm.
"The first I heard of it was on the day he died," she added.
Inquest also heard Dr Michael Hennessy, a consultant neurologist, who treated Mr Ryder for encephalitis was never made aware of the aneurysm. He added that had he been aware he would have referred the patient for vascular surgery assessment.
He added that Mr Ryder was suffering from " a very unusual and serious neurological disorder".
Mr Ryder was last admitted to hospital on November 19, 2011 but no attempt was made to treat the aneurysm until November 24. He died the following day on November 25, 2011.